Maggie McKay (Host): If you've struggled with your weight for years, it can be disheartening and frustrating. But today, Dr. Naser Gharaibeh, Medical Director of Metabolic Medicine and Weight, will discuss how medical weight loss can work for you. Welcome to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey.

Our podcast goes beyond broad everyday health topics to discuss very real and very specific subjects impacting men, women, and children. We think you'll enjoy our fresh take. Thanks for listening. Welcome Dr. Gharaibeh. So nice to have you here.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Thank you Maggie.

Host: Let's just start off with what is the definition of obesity and medical weight loss, obesity medicine?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Okay, this is a great question, because it sheds some light on the obesity pandemic, and the definition that we know of is not necessarily very accurate. So according to the WHO, obesity is defined by having a body mass index of more than 30. And overweight is defined by having a body mass index of 25 to 29.99. But the more accurate description of obesity, according to the Obesity Medicine Association, it's a chronic, complex, and relapsing, remitting disease associated with the fat mass disease, which focuses on the mechanical component of the disease, then also a metabolic component of the disease, in addition to a neurobehavioral component.

So, it's a relapsing, remitting disease. So when patients take medications for weight loss or they are enrolled in intensive lifestyle interventions, or even get weight loss surgery; they have to be aware that this is a relapsing, remitting disease. So sometimes the disease is under control, in other terms you're losing the weight or the weight is stable, but also the disease can come back, and this is true for all chronic diseases, including obesity.

Host: And before we get into medications, what are some of the procedures available?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: So, there are many procedures, and this is an evolving field still. Metabolic surgery or bariatric surgery is an evolving field. The most common surgeries are sleeve gastrectomy. Basically you create a banana shaped stomach and so a smaller size for the stomach and less capacity to, retain and eat food.

Or the Roux-en-Y gastric bypass. Which is a little bit more aggressive type of surgery, but also more effective.

Host: So those are the most common?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: That's correct.

Host: Okay. And is there a minimum BMI needed to get prescribed a weight loss drug?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: The indications for taking a medication or considering a medication for weight loss would be a body mass index of 30 and higher without comorbidities or a body mass index of 27 and higher with comorbidities such as high blood pressure, or diabetes, or obstructive sleep apnea.

And when we talk about medications, it's very important to go back to the first question talking about the definition of obesity medicine. It's a relatively new field. People think, oh, it's just about taking the medication, but the process of prescribing the medication is preceded by a thorough evaluation because the most important aspect of obesity management is to figure out the reason of the weight gain, because not all patients with obesity are the same.

And that's followed by lifestyle interventions, such as meal plan and physical activity. And here when I mention, meal plan and physical activity, I mean it. Because this is not a diet. So diets fail. Patients need to know that diets fail and exercise is not necessarily a good fit for all patients with obesity. And that's why we always use the term physical activity rather than exercise.

Host: And Dr. Gharaibeh, how exactly do these medications work in the body and in the brain?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: These medications you're talking about the more commonly prescribed medications because there are many prescribed for weight loss. So, as a category, we have the stimulants such as phentramine or Vyvanse, for example. And these medications, basically have a central action. So they work on the brain, but also have some cardiovascular effects and they increase the metabolism.

 So in a way they suppress the appetite. The newer and the more evolving medications, and there is a lot of vibe around them, the injectable medications such as semaglutide and tirzepatide, which are branded as Wegovy and Zepbound. These medications have both central and gastrointestinal mechanism of action.

So central action, it's a hypothalamic action where our centers for appetite send signals for you to feel hunger. So they suppress that ability. But also gastrointestinal effect, as they slow down the transit of food from the stomach to the intestine, which obviously can cause the common side effects, which are mostly gastrointestinal, such as nausea and vomiting.

Host: How do these medications compare to surgery for results and side effects? Because I've heard there are a lot of side effects to some of these medications.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: I think the most important thing to know, there is no best option for treatment, and we have to choose the best treatment option according to the patient characteristics and their goals. So if you have a like a bird view, look at these two options, whether surgery versus medications; surgery continues to be the most cost effective way of management of obesity. Obviously it's more intensive type of therapy, but the weight loss is more rapid. So some patients need that, but others don't necessarily need that. And it requires more extreme lifestyle modification. But if you're talking about long term, then surgery is maybe the most cost effective way because the medications, always, before I discuss the side effects of these medications and the long term use, I always discuss also the financial aspect of that because the cost of these medications is really significant.

So we're talking about like 500 to 1,000 a month. So that's an investment. Except if the medication is covered by the insurance plan, taking the medication long term is a challenge. But there are some benefits. I mean, you're talking about more gradual weight loss, which is a relatively good thing when it comes to weight management.

So the weight loss is not as drastic. You're not dealing with an irreversible change, basically in the anatomy, which is very important to know. And relatively you have to have minimal lifestyle modifications, but definitely increased physical activity and changes in diet are integral.

And people think taking the medication is like a magical pill or treatment. It's not. So if you don't pair the medication with lifestyle interventions, usually we don't see significant weight loss achieved.

Host: When a patient's enrolled in a medical weight management program, how much can they expect to lose?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Actually, I have seen some patients who were able to lose 10 pounds and others who were able to lose up to 200 pounds. So it all depends on the patient characteristics. And when we manage the weight, it's not necessarily about managing the weight, it's actually about managing the complications related to the obesity and frequently that includes fluid retention.

So those patients who have challenges with chronic liver disease or congestive heart failure, they're expected to relatively lose more weight than average. But if you say on average, basically in our program, an average person would lose 36 pounds over the first six months of the treatment.

But again, the range is very wide and it all depends on what the patient is able to take in terms of medications, their level of motivation in achieving or meeting their goals for lifestyle, and obviously multiple other factors that can be also hormonal. So in case we're dealing with a patient who has high cortisol, for example, or low thyroid levels; these patients typically achieve much more drastic weight loss. Again, not all patients with obesity are the same. And that's why it's difficult to say like, oh, this is the number.

But in general, success in a medical weight management program, success is defined by losing five to 10 percent of total body weight.

So if you are treating a patient with 300 pounds, then we would basically shoot for let's say 30 pounds of weight loss. But what's more important actually, Maggie, is maintenance of weight loss. Everyone thinks about achieving the weight loss. What's really important is maintaining the weight loss, because whether you're using surgery or medications, the biggest challenge is the drastic weight regain when we stop the lifestyle interventions or stop the medication or stop paying attention to basically all of that.

And that's why, again, the definition involves not the chronicity of the weight problem or obesity, but also that this is a relapsing, remitting chronic disease.

Host: Dr. Gharaibeh, you mentioned water retention. Is it accurate that our bodies are 80 percent water?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Well, not necessarily. So, regarding our body composition, when you're talking about the intracellular body composition of fluids. Yeah, I would say 60%.

So our fat mass, in a healthy patient who does not have obesity, would be 15 to 25% fat, 60 percent body water, and then 15 percent protein and 5 percent minerals.

But also patients with obesity, obesity is defined by having body fat percentage of more than 25 percent in men and 32 percent women. And the difference is related to testosterone, which is an anabolic hormone. And that's why there is some difference in body composition composition between men and women.

Host: And you mentioned, how we define success when it comes to weight loss. Did you say 5 - 10 percent of the person's original weight?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: That's correct. That's in general, the minimum.

Host: Is there anything else you'd like to add that we didn't cover?

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Just one last thing. That journey for weight loss, it's not really about losing weight on the scale. There is much more into that. As I mentioned, there are multiple complications related to obesity. So, when you're trying to lose the weight or be enrolled in any weight management program, whether it's surgical or medical, then one has to keep in mind that this is a journey where you regain control of your life.

You get out of your own way and focus on a very passive aspect of your life. This is really an investment in your health. We always talk about our financial health, like investing and, dedicate a lot of time for our retirement accounts, but we rarely think about our health as an investment. So when you enroll in such a program, or you take such a medication, or maybe consider weight loss surgery even, this is really an investment in your health where you don't necessarily just achieve the weight loss per se, but this is when you see an improvement in your level of motivation and your sex drive and your self-confidence.

And, also there are the mechanical aspects of the disease, the inflammatory aspects of the disease. So we're talking about markers of inflammation, talking about risk of having heart disease. And also the level of pain improves in patients who have bone on bone or osteoarthritis. So in our program, we take pride in having a comprehensive obesity management program where we look at all of these things.

So it's not just about losing 5 or 10 or 20 percent of your weight. It's about regaining control of your life.

Host: So it's kind of like a holistic approach.

I like that. What did you say? Get out of your own way.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Yes.

Host: Yeah, that's a good mantra for a lot of things. I like it. Well, this has been so helpful and informative. Thank you so much for making the time to share your expertise.

Naser E. Gharaibeh, MD, CPE, DABOM, NCMP: Thank you. And can't wait till we do it again.

Host: Absolutely, me too. Again, that's Dr. Naser Gharaibeh, and for more information about medical weight management at Valley, or to make an appointment, please visit valleyhealth.com/weightloss, or call 201-251-3480. To be connected with today's guest, please call 201-291-6090, 201-291-6090 or email valleypodcast at valleyhealth.com. If you found this podcast helpful, please share it on your social channels and check out our entire podcast library for topics of interest to you. I'm Maggie McKay. Thanks for listening to Conversations Like No Other, presented by Valley Health System in Ridgewood, New Jersey.